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Prevalence of Dementia and Dementing Diseases in Japan
The Tajiri Project
Kenichi Meguro, MD, PhD;
Hiroshi Ishii, MD;
Satoshi Yamaguchi, MD, PhD;
Junichi Ishizaki, PhD;
Masumi Shimada, PhD;
Mari Sato, MSc;
Ryusaku Hashimoto, MSc;
Yoichi Shimada, MSc;
Mitsue Meguro, BA;
Atsushi Yamadori, MD, PhD;
Yasuyoshi Sekita, PhD
Arch Neurol. 2002;59:1109-1114.
ABSTRACT
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Background Vascular dementia (VaD) has been considered to be more prevalent than
Alzheimer disease in Japan. However, this might be the result of overdiagnosis
stemming from some problematic diagnosis of VaD or of the frequent use of
magnetic resonance imaging to detect cerebrovascular disease in older adults.
Objectives We investigated the prevalence of dementia and the ratios of dementing
diseases. The effects of different criteria for VaD (DSM-IV, Alzheimer's Disease Diagnostic and Treatment Centers [ADDTC], and
National Institute of Neurological Disorders and Stroke and the Association
Internationale pour la Recherche et l'Enseignement en Neurosciences [NINDS-AIREN])
were considered. Hippocampal atrophy and vascular contribution to dementia
were evaluated using magnetic resonance imaging findings.
Methods We targeted all residents 65 years and older (n = 3207) in Tajiri, Japan,
and examined 1654 (participant group 1). Of these, 564 (participant group
2) were randomly selected, and 497 underwent magnetic resonance imaging and
diagnosis of dementing diseases.
Results We found the overall prevalence of dementia to be 8.5% (141/1654) in
participant group 1. Of these, 21 (14.9%) had a history of stroke. Of the
113 participants who had a history of stroke independent of dementia, 18.6%
(21/113) were demented. For participant group 2 (n = 497), 32 were demented.
The ratio among the dementia for probable VaD based on the NINDS-AIREN criteria
was 18.8% (6/32), whereas that for ischemic vascular dementia was 31.3% (10/32)
according to the ADDTC criteria.
Conclusion We confirmed the overall prevalence of dementia in adults 65 years and
older to be 8.5%. We found that VaD was not a common disorder according to
the NINDS-AIREN criteria. Rather, the condition of possible Alzheimer disease
with cerebrovascular disease was more common.
INTRODUCTION
FOR COUNTRIES with large populations of older adults, knowledge of the
prevalence of dementia is needed for health policy planning. Most studies
reported the prevalence to be greater with older age.1-2
Vascular dementia (VaD), rather than Alzheimer disease (AD), has been
believed to be the most common dementing condition in Japan.3
However, the diagnostic criteria for VaD are problematic. The DSM-IV4 requires "laboratory evidence
indicative of cerebrovascular diseases that are judged to be etiologically
related to the disturbance" for a diagnosis of VaD. Confirmation of etiologically
related cerebrovascular disease (CVD) requires sophisticated neurological
knowledge.
Also, the higher prevalence of suspected "vascular lesions," which are
frequently detected as high-signal intensity on T2-weighted magnetic resonance
imaging (MRI) findings,5 might result in overdiagnosis.
Because of the increasingly common practice of performing MRI, some patients
might have received a diagnosis of VaD simply because they were demented and
had CVD.
Other criteria were developed in an attempt to overcome this problem.
The Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC) criteria6 require evidence of 2 or more strokes or a single
stroke with a clear temporal relationship to the onset of dementia. The criteria
of the National Institute of Neurological Disorders and Stroke and the Association
Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN)7 state that a causal relationship between CVD and dementia
is required for a diagnosis of VaD and propose that the conditions under which
patients with dementia and concomitant CVD may be considered to have possible
AD with CVD. We suspect that many cases previously overdiagnosed as VaD in
Japan might better have been diagnosed as possible AD with CVD.
Pohjasvaara et al8 found that the different
criteria for VaD were not interchangeable. Major discriminating factors between
the criteria were the requirements of focal neurological signs, unequal distribution
of cortical dysfunctions, and evidence of relevant CVD based on neuroimaging
findings.
Since we suspected that the previously reported high prevalence of VaD
in Japan was due to overdiagnosis, we sought to confirm this low interchangeability
of the criteria by means of a community-based study. Therefore, we examined
MRI findings in older adults in a community for the prevalence of dementia
and the ratios of dementing diseases, with a focus on VaD.
PARTICIPANTS AND METHODS
PARTICIPANT GROUP 1
Based on the Tajiri Project, a community-based study on stroke, dementia,
and bed-confinement prevention in Tajiri, a typical agricultural area in northern
Japan,2, 9-11
we targeted all residents 65 years and older (N = 3207). We did not use a
screening test design; the survey included Clinical Dementia Rating (CDR)
assessments,12 dementia diagnosis, and results
of a neuropsychological examination (not reported herein). The survey requested
agreement for all components.
We included 1654 participants (51.6%) in the study. The participants/population
for each age group were 404/1066 (65-69 years), 560/856 (70-74 years), 348/607
(75-79 years), 212/397 (80-84 years), and 130/281 ( 85 years). The reasons
for refusal to participate were mainly psychological (25.6%) and physical
(14.6%). Each age group satisfied the statistically sufficient number for
the confidence interval to be 95%, provided that the prevalence of dementia
was 10%. Home interviews were performed for 87 participants. Fifteen participants
were reported by families to be confined to bed; 8 of these participants,
however, were able to maintain a sitting position without support. A medical
history of stroke was present in 113 (6.8%) of the 1654 participants.
PARTICIPANT GROUP 2
From among the population of 1654, 564 adults were randomly selected
to undergo MRI. The cost of all MRIs was officially paid for by the town government
(about $300 per person). Finally, 497 participants agreed to undergo MRI. Figure 1 illustrates the study design. Written
informed consent was obtained from all healthy participants and from the family
members of patients with dementia.
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Figure 1. We targeted all residents in the
town of Tajiri, Japan, aged 65 years or older (N = 3207). Of these, 1654 (51.6%)
participated in the study (participant group 1). From among this population,
564 adults were randomly selected to receive magnetic resonance imaging (MRI).
Finally, 497 participants (88.1%) (Participant Group 2) agreed to undergo
MRI.
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MAGNETIC RESONANCE IMAGING
Using MRI (1.5 T; SIERRA, GE-YMS, Japan), we evaluated hippocampal atrophy
and CVD lesions, since both are important for the diagnosis of dementia.
For hippocampal assessment, the T1-weighted (repetition time/echo times,
400/14 ms) plane along the long axis of the hippocampus showing the measurement
point described by Jobst et al13 was selected.14 Using the semiaxial plane, we measured the minimum
width of the hippocampus13 and divided by the
brain width on the same plane (defined here as the hippocampal width [HippW]).14 The HippW (given as a percentage) was measured by
2 board-certified neurologists independent of this study. Each neurologist
made 2 assessments. The interreader and intrareader reproducibilities were
calculated as follows:
For the interreader reproducibility, HippW1 and HippW2 were assessed by 2 neurologists. For the intrareader reproducibility,
HippW1 and HippW2 were assessed by the same neurologist.
Both results were better than 95%.
For the CVD evaluation, the combined axial T1-weighted and T2-weighted
(repetition time/echo time, 3000/90 ms) images were used. Lesions were considered
to be CVD when they showed low intensity on the T1-weighted MRI and high intensity
on the T2-weighted MRI at the same location. We operationally classified CVD
into the following 3 categories: (1) those smaller than 4 mm in size (defined
here as état criblè), (2) those 4 to 8 mm (small CVD), and (3)
those larger than 8 mm (large CVD).15 We counted
the CVD numbers and assessed the moderate and large CVD distributions. After
independent assessment by the 2 neurologists, the final evaluation was made
by a third senior neurologist (K.M.).
ANALYSIS OF PARTICIPANT GROUP 1
We calculated the prevalence of dementia for both sexes in each age
group. For the effect of educational level, participants were classified into
the following 3 groups according to the old Japanese system: 6, 8, and 10
or more years of schooling. Dementia was diagnosed by means of the DSM-IV criteria. Severity of CDR was decided by a clinical team consisting
of a psychiatrist, neurologists, and public health nurses. They assessed the
subjects' mental status by asking them about their daily lives and family
situations. The patients with dementia exhibited a CDR rating of 1 or greater.
Using the 113 participants who had a history of stroke, the prevalence of
poststroke dementia was also calculated. For MRI measures, we evaluated the
HippW of each CDR and age group and the prevalence of CVD.
ANALYSIS OF PARTICIPANT GROUP 2
For the patients with dementia (diagnosed by means of the DSM-IV criteria), we analyzed the dementing diseases using the following
criteria: (1) DSM-IV for dementia of the Alzheimer
type (DAT), (2) DSM-IV for VaD, (3) National Institute
of Neurological and Communicative Disorders and Stroke and Alzheimer's Disease
and Related Disorders Association16 for probable
AD, (4) NINDS-AIREN for possible AD with CVD, (5) NINDS-AIREN for probable
VaD, and (6) ADDTC for probable ischemic vascular dementia (IVD).
Based on a previous study,8 the presence
of focal neurological signs for the diagnosis of VaD included at least 1 of
the following: hemianopia, lower facial weakness, dysarthria, motor or sensory
hemisyndrome, hemiplegic gait, or a positive Babinski sign.
Since the poor interchangeability of the criteria for VaD was reported,8 we used only the probable criteria. Patients received
a diagnosis of possible AD with CVD by means of the NINDS-AIREN criteria,
provided that the vascular effect on dementia was considered to be too ambiguous
to diagnose as VaD.
The Hachinski Ischemic Scale (HIS)17
was also used to evaluate the possible effect of differential diagnosis. For
MRI measures, regional CVD distribution in dementia was also evaluated.
RESULTS
PARTICIPANT GROUP 1
Figure 2 illustrates the prevalence
of dementia. Overall, 64 (9.2%) of 694 male participants and 77 (8.0%) of
960 female participants received a diagnosis of dementia; 141 (8.5%) of 1654
participants had dementia.
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Figure 2. For male and female participants,
the prevalences of dementia were 3.5% and 0.9%, respectively, in the group
aged 65 to 69 years; 5.0% and 1.9%, respectively, aged 70 to 74 years; 3.9%
and 11.0%, respectively, aged 75 to 79 years; 21.9% and 14.7%, respectively,
aged 80 to 84 years; and 33.9% and 39.4%, respectively, aged 85 years and
older. Overall, 9.2% of male participants and 8.0% of female participants
received a diagnosis of dementia.
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For the effect of educational level, the prevalence of dementia was
15.5% (38/245), 7.7% (89/1157), and 5.6% (14/252) for the groups with 6, 8,
and 10 or more years of schooling, respectively.
Dementia was present in 21 (18.6%) of the 113 participants who had a
history of stroke, who constituted (14.9%) of the 141 participants with dementia.
These 21 participants met the NINDS-AIREN criteria for possible VaD.
Table 1 gives the HippW
value of each CDR group. Owing to incomplete MRI findings in 5 cases, 492
participants underwent analysis. A significant CDR effect was noted.
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Table 1. Right-Left Mean Hippocampal Width of Each CDR Group*
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For the prevalence of état criblè, the mean total numbers
(bilateral sides) ± SE were 4.1 ± 0.3 (CDR, 0), 3.8 ±
0.5 (CDR, 0.5), and 6.6 ± 1.1 (CDR, 1). Results of 1-way analysis
of variance (ANOVA) showed no significant CDR effect with a significant covariant
effect of age (F = 15.635; P<.001).
For small CVD, the numbers were 0.4 ± 0.1 (CDR, 0), 0.6 ±
0.1 (CDR, 0.5), and 1.1 ± 0.2 (CDR, 1). We found a significant
CDR effect (F = 6.296; P = .002), with no effect
of age. For large CVD, the numbers were 0.2 ± 0.04 (CDR, 0), 0.4 ±
0.1 (CDR, 0.5), and 0.7 ± 0.1 (CDR, 1). We also found a significant
CDR effect (F = 7.225; P = .001), with no effect
of age.
PARTICIPANT GROUP 2
Thirty-two participants received a diagnosis of dementia. Figure 3 shows the dementing diseases. The ratios of probable AD,
possible AD with CVD, and probable VaD are shown. For these 3 diagnoses, the
2 neurologists were in perfect agreement. The prevalence of VaD was not as
common as previously believed. The most common condition was possible AD with
CVD. Other conditions included frontotemporal dementia,18
dementia with Lewy bodies,19 hypoxic encephalopathy,
posttraumatic dementia, and alcoholic dementia.
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Figure 3. The most common dementing disease
in Tajiri, Japan, was possible Alzheimer disease (AD) with cerebrovascular
disease (CVD) (by means of the National Institute of Neurological Disorders
and Stroke and the Association Internationale pour la Recherche et l'Enseignement
en Neurosciences criteria), followed by probable AD (by means of National
Institute of Neurological and Communicative Disorders and Stroke and Alzheimer's
Disease and Related Disorders Association criteria). It seemed that vascular
dementia (VaD) tends to be overdiagnosed if possible AD with CVD is thought
to be VaD.
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Although the diagnoses by the 2 neurologists of the 3 conditions described
in the previous paragraph were in agreement, the condition of possible AD
with CVD was heterogeneous. As given in Table 2, this condition can be classified into 3 subgroups.
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Table 2. Regional CVD in Patients With Possible AD With CVD and VaD*
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Subgroup 1
Patients in this subgroup had probable AD with concomitant, nonstrategic
CVD. They met the DSM-VI criteria for DAT, but did
not meet the ADDTC criteria for IVD. The 2 neurologists completely agreed.
Subgroup 2
Patients in this group did not meet the ADDTC criteria for probable
IVD, and the 2 neurologists did not completely agree on the DSM-IV–based diagnosis of DAT or VaD. Thus, both possibilities
existed (described as DAT/VaD).
Subgroup 3
Patients in this group met the ADDTC criteria for probable IVD. There
was complete agreement by the 2 neurologists, despite the fact that the NINDS-AIREN
criteria for VaD were not satisfied. No complete agreement was obtained for
the DSM-IV criteria, as with subgroup 2.
The mean ± SE HIS values were 2.2 ± 0.8, 4.1 ±
0.5, and 6.7 ± 0.8 for the groups with probable AD, possible AD with
CVD, and probable VaD, respectively. Results of 1-way ANOVA disclosed a significant
group effect (F = 7.664; P = .003), with the post
hoc test showing a higher VaD score compared with the probable AD score
(P = .004).
The HippWs (left-right mean ± SE) were 8.4% ± 1.0%, 6.0%
± 0.6%, and 8.7% ± 1.0% for the groups with probable AD, possible
AD with CVD, and probable VaD, respectively. Results of 1-way ANOVA disclosed
a significant group effect (F = 3.782; P = .04) with
no effect of age, with the post hoc test showing a smaller tendency of possible
AD with CVD compared with that of probable VaD (P
= .08).
As for the regional CVD distribution for dementia with CVD, 6 patients
with a diagnosis of VaD (by means of NINDS-AIREN criteria) met the ADDTC criteria
for IVD and the DSM-IV criteria for VaD. The 2 neurologists
were in perfect accordance as to the VaD diagnosis for these patients. The
patients tended to have CVD in bilateral basal ganglia regions, except for
the putamen, or at least unilateral large cortical CVD. For the groups with
AD and CVD, mostly nonstrategic areas were affected by CVD.
COMMENT
Some methodological issues should be mentioned first. Although the number
of patients in participant group 1 was sufficient for the confidence interval
to be 95%, the response rate was relatively low. For refusals to participate
due to psychological reasons, we considered that asking test questions to
older adults might be culturally inappropriate. For refusals owing to physical
reasons, although we attempted to perform home interviews, the refusal rate
was greater than 50%. Therefore, the low prevalence of VaD might have resulted
from the families of the most severely affected residents refusing to participate
in the survey. Also, the number of patients in participant group 2 was small
due to economic limitations. Among participant group 2, 32 people (6.4%) received
a diagnosis of dementia, the prevalence being lower than that among participant
group 1. This was due to the older subjects' difficulty in undergoing MRI.
Although these 32 people were from a randomly selected sample, we should be
cautious about the findings of such a relatively small sample.
A poor interchangeability of the VaD criteria was reported.8 We have not herein reported the  values because
the number of patients was relatively small; because we used only the probable
criteria; and because probable AD and probable VaD were in perfect accordance.
For MRI methods, precise volumetry is recommended.20
However, the MRI equipment used in this study did not allow us to perform
volumetry. We instead measured the HippW that was available for clinical study.21 Despite these limitations, we consider that the results
yielded some information on dementia in Japan.
PREVALENCE OF DEMENTIA
The high prevalence of dementia in Tajiri was previously discussed.2 Surveys conducted in communities that have higher
rates of out-migration to nursing homes have a lower prevalence. On the contrary,
surveys in communities such as Tajiri and East Boston, Mass,1
which have lower out-migration owing to strong family support systems, tend
to have a higher prevalence. Strong family support exists in Tajiri, where
3 generations often live in the same house.2
This tendency does not differ between demented and nondemented older adults.
Previously, we estimated the overall prevalence of dementia among adults 65
years and older to be 8.0%.2 We herein identified
it to be 8.5%.
The increasing prevalence of dementia with age easily leads to the misconception
that dementia is inevitable with aging.22 However,
a meta-analysis of epidemiological studies23
concluded that dementia is better conceptualized as an "age-related" rather
than an "aging-related" disorder. Results of neuropsychological investigations
of healthy older adults11 and longitudinal24 studies on screening test performances during a 5-year
period support that idea. However, further investigation is needed for the
oldest old population or for the longitudinal incidence.
The prevalence of dementia was high in those with lower levels of education.
Although the effect of education has not been fully analyzed compared with
that of age, analysis of all such effects has disclosed the prevalence to
be high in subjects with lower levels of education.25
Mortimer and Graves26 suggested that education
could induce dendritic growth and that more highly educated people are protected
to some degree against AD. However, Filley et al27
found no protective effect of education. Moreover, educational level may merely
be a marker of other socioeconomic determinants such as nutrition. Further
investigation is needed to clarify this point.
DEMENTING DISEASES IN JAPAN
Our results showed possible AD with CVD to be the most common dementing
condition in Japan, contrary to the previous assumption that VaD is the most
common dementing condition in Japan. As described earlier, the different criteria
for VaD are not interchangeable.8 The biggest
reason is the difficulty in identifying the type of CVD responsible for dementia.
Participants with AD and CVD in subgroups 1 and 2 did not meet the ADDTC criteria
for IVD, but met the DSM-IV criteria for DAT, since
the vascular effect on dementia was considered to be too ambiguous to diagnose
as IVD.
Confirmation of this etiologically related CVD requires sophisticated
neurological knowledge. With recent developments of MRI technology, even small
signal abnormalities can be easily detected. Some are apparently état
criblè or perivascular space dilatation. A nonspecialist might easily
misdiagnose this condition as VaD simply because the patient was demented
and showed MRI abnormalities. The lower prevalence of VaD was supported by
the analysis of poststroke dementia. These participants met the NINDS-AIREN
criteria for possible VaD. However, we could not rule out the possibility
that some residents who had refused to participate owing to physical reasons
might be affected by VaD.
Another possibility is that the prevention of CVD has at least been
partially successful in Japan, subsequently resulting in a lower prevalence
of VaD compared with those of previous reports. Kiyohara et al28
compared 2 surveys of residents of Hisayama, Japan, conducted in 1985 and
1992. The overall prevalence of dementia was decreased from 5.4% to 3.3% for
men and 7.5% to 6.3% for women. The prevalence of AD was the same for both
sexes. A longitudinal incidence study is planned for participant group 1.
VASCULAR CONTRIBUTIONS TO DEMENTIA
The results indicate that état criblè was related to aging
but not to dementia. Instead, the numbers of small or large CVD had some effect
on dementia. The results of CVD distributions indicated that bilateral involvement
of the basal ganglia region, except for the putamen, or at least unilateral
cortical CVD, is associated with dementia. Global neural disconnection based
on even subcortical vascular lesions might be associated with VaD, such as
in AD as a disconnection syndrome.29 Global
cortical glucose use was related to cognitive decline.30
Although the number of patients with dementia was small, we found that
the HIS and the HippW were effective for distinguishing VaD or possible AD
with CVD from other dementing conditions. The HIS was effective for separating
VaD from probable AD. The HippW was smallest in the group with possible AD
with CVD compared with probable VaD. This finding suggests that hippocampal
atrophy was caused by AD traits and vascular lesions. The hippocampus is vulnerable
to degenerative and general conditions.31
Two extreme concepts regarding CVD and dementia are possible. One is
that there is no concept for VaD. As a matter of course, large infarctions
can affect 2 or more cognitive domains, thus resulting in satisfaction of
the criteria of VaD. However, small infarctions should not be considered as
primary dementing conditions. What was previously considered as VaD is actually
additional CVD in background AD pathologic characteristics resulting in the
progression of dementia pathogenesis. Therefore, all VaD should be categorized
as possible AD with CVD. The Nun study32 found
that the vascular contribution to dementia was not primary but additive to
the background AD pathologic traits.
An alternative is that the vascular factor should be considered as primary.
The effectiveness of the HIS found in this study supports that concept. Central
executive dysfunction could be the hallmark symptom of VaD,33
as memory impairment is of AD. Hachinski and Bowler34
proposed the concept of vascular cognitive impairment, whereas Erkinjuntti
et al35 presented criteria for subcortical
VaD. A further investigation based on extensive neuropsychological examination
is needed to clarify this subject.
AUTHOR INFORMATION
Accepted for publication March 13, 2002.
Author contributions: Study concept and design (Drs Meguro, Ishii, Yamadori, and Sekita and Messrs Sato and Hashimoto); acquisition of data (Drs Meguro, Ishii, Yamaguchi,
and Shimada and Messrs Ishizaki, Sato, Hashimoto, Shimada, and Meguro);
analysis and interpretation of data (Drs Meguro and Ishii
and Messrs Ishizaki, Sato, and Hashimoto); drafting of the manuscript (Dr Meguro); critical revision of the manuscript for important
intellectual content (Drs Meguro, Ishii, Yamaguchi, Shimada,
Yamadori, and Sekita and Messrs Ishizaki, Sato, Hashimoto, Shimada, and Meguro); statistical expertise (Dr Meguro); obtained
funding (Dr Meguro); administrative, technical, and
material support (Drs Meguro, Ishii, and Yamaguchi and Messrs
Ishizaki, Sato, and Hashimoto); study supervision (Drs Meguro, Yamadori, and Sekita).
Corresponding author and reprints: Kenichi Meguro, MD, PhD, Division
of Neuropsychology, Department of Disability Medicine, Tohoku University Graduate
School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan (e-mail: meg{at}mail.cc.tohoku.ac.jp).
From the Division of Neuropsychology, Department of Disability Medicine,
Tohoku University Graduate School of Medicine (Drs Meguro, Ishii, Yamaguchi,
Ishizaki, Shimada, and Yamadori; Miss Sato; and Messrs Hashimoto and Shimada,
Sendai), The Tajiri SKIP Center (Dr Ishii), Tajiri; and the Division of Health
Care System Science, Department of Planning for Welfare Programs and Public
Policy, Tohoku University Graduate School of Economics (Mrs Meguro and Dr
Sekita), Sendai, Japan.
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